A practice in the Wiltshire area

6. Mr D complains the about the care and treatment provided by the Practice between October 2023 and April 2025. He says the Practice:

• failed to refer him to OpRestore as early as it should have • failed to follow up on his blood pressure readings • acted unprofessionally during a phone call.

7. Mr D says the Practice’s actions have caused him to experience aggravation, irritation, upset and distress which have all had a negative impact on his mental health and wellbeing. He also says these failures mean he did not receive appropriate clinical care as early as he should have.

8. Mr D wants the Practice to apologise for what it got wrong, make service improvements and make a financial payment.

9. Mr D is a veteran. He had been experiencing difficulties with a meniscal tear in the right knee and was seeking support from a veteran’s charity. A veteran’s community nurse emailed the Practice in October 2023 to request that the Practice refer Mr D to OpRestore. This is an NHS service that supports individuals who have served in, or are leaving, the UK armed forces and have continuing, physical health injuries and related medical problems attributed to their time in the armed forces.

10. The email explained that OpRestore would be able to review Mr D’s care and treatment for the injuries and chronic pain he had sustained as a result of his time in Service. Mr D also chased the referral request the next day.

11. The Practice sent the referral at the end of January 2024.

12. OpRestore wrote to the Practice in July 2024 to advise it Mr D may benefit from a referral to a musculoskeletal (MSK) team for his ankles, shoulder and left knee. It asked the Practice to highlight that Mr D is a veteran and that the injuries were service-related. This would mean that Mr D would be listed for care sooner. The Practice made the referral two weeks later.

13. OpRestore also asked the Practice to discuss a possible mental health referral to OpCourage, which is the veteran’s mental health and wellbeing service.

14. At the end of September 2024, the Practice asked Mr D to monitor his blood pressure at home for seven days and record the readings on a form. Mr D emailed a copy of the form to the Practice. The form advised patients to contact the Practice if they do not hear back within two weeks. Mr D emailed the Practice two weeks later to ask about his results. The Practice did not respond. No further action was taken at this time.

15. In October 2025, Mr D’s blood pressure was above target. The Practice documented Mr D was not keen on taking medication for this, was working on his diet and lifestyle, and preferred his bloods to be tested before starting any new medication. Mr D’s blood tests came back normal, and the Practice started Mr D on medication to control his blood pressure in November 2025.

16. During a phone call in April 2025, it is documented the Practice advised Mr D of a local Practice if he wishes to register with it.

20. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the events complained about had a negative effect which the organisation has not put right. Having done so we have found the Practice has already done enough to put right the impact of these events.

Referral

21. Mr D complains the Practice caused a delay to his referral to OpRestore in October 2023. He says this means he did not receive appropriate clinical care as early as he should have.

22. The Practice acknowledged it did not manage Mr D’s referral to OpRestore as well as it should have and apologised for the delay this caused. It explained it has since employed an experienced practice manager who has been auditing the way it manages referrals. The Practice manager has clarified its processes for the way it manages the completion of forms.

23. Our Principles of Good Administration say public bodies should handle and process information properly. Public bodies should also behave helpfully and deal with people promptly.

24. Our GP adviser said there is no formal guideline to say how long a Practice should take to complete a routine referral. They said the referral does appear to have taken longer than would be considered usual. We think the time the Practice took to compete the referral was not in line with our Principles of Good Administration as it took 13 weeks to process it. We have considered the impact of this delay on Mr D’s clinical care and treatment.

25. We recognise Mr D’s concern the time the Practice took means he did not receive appropriate clinical care as early as he should have. We have considered the impact of the delay on Mr D’s clinical care and treatment.

26. Firstly, we have considered the referral the Practice made to MSK in August 2024. It is documented the Practice noted Mr D is a veteran and included the letter from OpRestore.

27. MSK contacted Mr D to attend an assessment for 11 weeks later. Our GP adviser explained waiting times for MSK services are not fixed and can fluctuate significantly each month. This is because the amount of referrals MSK receives each month is different. They said it is not possible to reliably predict when MSK would have assessed Mr D if he had been referred earlier.

28. Due to this we do not know if MSK would have assessed Mr D earlier than it did, had the Practice completed the referral earlier. This means we are unlikely to be able to say if there was any clinical impact of this delay on Mr D. We appreciate this may cause Mr D further upset.

29. Next, we have considered the referral to OpCourage. The Practice did not refer Mr D to OpCourage. Mr D told us that after the Practice sent him a copy of the OpRestore document, he did not ask it to refer him to OpCourage as he does not want this referral to take place. As Mr D told us he does not want to access OpCourage, we do not think there are indications the delay to OpRestore has had any impact on Mr D accessing this service. We think this means there was no clinical impact on Mr D of the Practice’s failure to complete the referral earlier.

30. At this point we think the delay in referral did not have a clinical impact on Mr D as he told us he does not want to access OpCourage. We are unable to say that MSK would have assessed Mr D any earlier than it did. We do think the delay in referral caused Mr D to experience frustration.

31. Our Principles for Remedy explain when things go wrong, we expect organisations to apologise, take responsibility and take remedial action to prevent the same thing from happening again. This can include revising procedures and training and supervising staff.

32. The Practice has apologised and acknowledged its failure to process the referral in a timely manner. This is in line with our Principes for Remedy and with what Mr D told us he wanted.

33. The new Practice manager is carrying out audits of the referrals the Practice makes. We think this is a form of supervision in line with our Principles for Remedy. The Practice manager has also clarified the process for completing referrals. We consider this is a form of training in line with our Principles for Remedy. Service improvements are in line with what Mr D told us he wanted. We hope this reassures Mr D the Practice have taken action to prevent this from happening again.

34. It is understandable Mr D has experienced frustration and distress. We hope our explanation clearly explains why we think the action the Practice has already taken is enough to put this right.

Blood pressure

35. Mr D complains the Practice did not follow up on his home blood pressure readings taken in September 2024, or acknowledge his email when he followed this up. He says this means he did not receive appropriate clinical care.

36. The Practice apologised and acknowledged that its failure to follow up on Mr D’s blood pressure results and the email he sent were failures in its performance. It said it receives thousands of documents every week and Mr D’s email went missing.

37. We think the Practice losing Mr D’s blood pressure results and not responding to his email are indications of a failing in line with our Principles of Good Administration. We think the Practice did not handle or process Mr D’s blood pressure results appropriately, as they went missing. We think the Practice did not behave helpfully or promptly when it did not respond to Mr D’s email.

38. It is understandable these issues have caused Mr D to experience upset and to worry he has missed out on appropriate clinical care. We have considered this.

39. NICE guidelines say clinicians should confirm a diagnosis of hypertension in people with a blood pressure of 140/90 or higher.

40. Our GP adviser calculated Mr D’s average blood pressure using the readings he submitted to the Practice. Our adviser said this was 127/79.

41. We think if the Practice had processed Mr D’s blood pressure results in line with our Principles of Good Administration, it would not have made any difference to the clinical care and treatment he received. This is because Mr D’s results were in the normal range for adults and did not meet the NICE criteria for further investigation. We hope this reassures Mr D the Practice’s failure to process his results do not appear to have had any clinical impact.

42. The Practice has apologised to Mr D and took responsibility for its failure to process the results and reply to his email. This is in line with our Principles for Remedy.

43. The Practice has also taken action to try and prevent similar failings from happening in the future. We can see it has appointed a new Practice manager to oversee and audit administrative processes. We consider this is a revision of the Practice’s previous procedures and ensures appropriate supervision is in place. This is in line with our Principles for Remedy to ensure poor service is not repeated.

44. Mr D told us he is seeking an apology and service improvements, so the Practice’s actions here are in line with what he told us he wants.

45. We were sorry to hear of Mr D’s concern the Practice did not follow up on his blood pressure readings. Mr D followed this up in line with the instructions on the form. We understand how frustrating it must have been when the Practice did not reply.

46. We hope our explanation reassures Mr D we have not seen this indication of a failing has had an impact on his clinical care and that the Practice has taken appropriate action to try and prevent similar failings from happening again. We can see the Practice advised Mr D of the action it has already taken to improve its service in its final response to him and acknowledged it then started him on the correct medication when his blood pressure became high in November 2025. We will therefore take no further action as the Practice has acted to put things right here.

Phone call

47. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

48. Mr D says the Practice acted unprofessionally during a phone call. He says the Practice told him he can register with another Practice if he is unhappy.

49. The Practice said as Mr D had expressed dissatisfaction with its services it made him aware of his right to register at any GP surgery. It said it suggested a Practice it thought would be convenient for Mr D’s home address.

50. The NHS constitution says that patients have the right to choose which GP Practice to register with.

51. We recognise Mr D experienced distress as a result of the Practices comment. We think what the GP said to Mr D reflected what the NHS constitution says about a patient’s right to choose their GP Practice.

52. As we have not seen any indications the Practice did anything wrong here, we will be taking no further action.

53. In summary, we have not seen the Practice did anything wrong when it made this comment. This comment was in line with the NHS constitution which says a patient has the right to choose their own GP Practice. We hope our explanation reassures Mr D we have not seen any indication of a failing in its decision to make this comment.

Conclusion

54. We would like to take this opportunity to thank Mr D for bringing his complaint to us. We hope our work helps to reassure him that where we have seen indications of failings, the Practice has taken appropriate action by apologising to him and making improvements to prevent similar failings from happening again.

1. We have carefully considered Mr D’s complaint about the Practice. We are sorry to hear of the concerns he has about the care he received. We recognise the Practice’s handling of Mr D’s blood pressure results and referral have caused Mr D to worry he has not received appropriate clinical care. We appreciate the Practice’s communication during a phone call has added to this distress.

2. We have seen indications of service failings because the Practice:

• did not refer Mr D to OpRestore (an NHS service which provides support to veterans) as early as it should have • lost a copy of Mr D’s home blood pressure readings and did not reply to his email when he chased this up.

3. We have not seen there was a clinical impact of these failings. We consider these failings caused Mr D distress and upset. We can see the Practice has acknowledged these mistakes, apologised and introduced service improvements to address them. We therefore consider the Practice has put things right here, and do not consider further action is needed.

4. We have seen no indications of failings in the Practice telling Mr D he is able to register with a new GP.

5. We have decided not to consider Mr D’s complaint further. Where we have seen indications of a failing, we think the Practice’s actions are enough to put this right and are in line with what Mr D told us he wants.